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Based on record review, physician and staff interview one of one Patient's fell post-recovery with a sustained injury following an invasive procedure which required sedation in August 2009. It was alleged the patient was taken to the bathroom and left unattended.

The findings are as follow:

The Patient was scheduled for an elective procedure with sedation in the Interventional Radiology Department on 08/13/09.

Review of the History and Physical Examination dated 08/06/09 by the Nurse Practitioner indicated the Patient had a history of falls and compression fractures of the spine.

Review of the Medical Day Care Center record indicated the Patient was brought to the outpatient center prior to the procedure. The Patient arrived ambulatory. However, there was no documentation the Patient had a history of falls,nor identified as being at risk for fall. There was no section on the Medical Day Care Center screening form to document the safety concerns for a Patient at risk for falls.

Registered Nurse #3 was interviewed on 04/21/10 at 1:45 PM. Registered Nurse #3 assessed the Patient prior to the procedure. Registered Nurse #3 said to determine the patients risk for falls, the patient's gait and transfer ability would be observed. Registered Nurse #3 said the patient did not have a history of falls because it would have been documented. Registered Nurse #3 did not review the Patient's electronic medical record for the History and Physical Examination. Registered Nurse #3 said the patient's fall assessment was not done until admission to the Hospital.

Review of the Patient's Nursing Progress Note for Medical Day Care Center dated 08/13/09 at 3:45 PM and as reported by staff, the Patient was ambulated to the bathroom and found on the floor by a visitor. The Nursing Progress Note indicated the Patient sustained a bruise and right elbow laceration. The Nursing Progress Note indicated the Radiologist (who performed the Interventional Radiology procedure evaluated the Patient) was called and evaluated the Patient.

There was no written physician progress note post-fall identifying the Patient's assessment for injury or fall until 08/14/09 at 12 PM.

On 08/13/09 at 5:20 PM, Registered Nurse #1 indicated in the Functional Assessment that the Patient was at risk for falls. Registered Nurse #1 recommended the Patient be evaluated by a physical therapist.

There was no documentation the Patient was evaluated by a physical therapist prior to discharge to a long-term care facility.

Registered Nurse #2 was interviewed in person on 04/21/10 at 11:30 AM. Registered Nurse #2 said patients undergoing the invasive procedure were kept flat initially and then according to protocol raised to an upright sitting position. Registered Nurse #2 said the Patient was then positioned on the edge of the stretcher prior to being assisted to the bathroom. Registered Nurse #2 said the Patient requested a rolling walker, so one was provided. Registered Nurse #2 said the Patient was instructed to push the call bell button, located on the wall. Registered Nurse #2 said the patient requested a rolling walker and one was provided. Registered Nurse #2 left the Patient unattended.

Review of the Admission Nurses Note dated 08/13/09 at 6:20 PM indicated the patient was alert. the Patient complained of right elbow pain. The Patient denied having any backpain. Registered Nurse #4 indicated the Patient had a large ecchymotic site dressed with a Tegaderm and gauze. The affected area had scant bleeding and the dressing was intact. Registered Nurse #4 applied an ice pack. The Patient was provided with a bed alarm.

On 08/14/09 at 12 PM, Radiologist #2 indicated the Patient apparently had a fall post-procedure. Radiologist #2 indicated the Patient reported having right elbow pain. Radiologist #2 indicated the Hospitalist and an Orthopedic Surgeon were consulted to evaluate the Patient.

Radiologist #2 was interviewed in person on 04/21/10 at 3:40 PM. Radiologist #2 said physician hand-off was communicated via a message board located in the Interventional Radiology Department. Radiologist #2 had no verbal communication with Radiologist (#1). Radiologist #2 denied having any knowledge of the Patient's fall. Radiologist #2 said the Patient reported someone checked it out (the right elbow), the previous day. Radiologist #2 said the Patient reported the right elbow was painful. Radiologist #2 said trauma patients were not evaluated by the Radiology Department; so a consultation was obtained with the Hospitalist. Radiologist #2 said the Patient's x-ray taken on 08/14/09 showed a fracture. Radiologist #2 said the Patient's fall had not been reported at the time of transfer of care.

The Nurse Manager for an inpatient unit was interviewed on 04/21/10 at 2:40 PM. The Nurse Manager said the Hospital had a Falls Prevention Program which reviewed data for both patient falls with and without injury.The Nurse Manager said the outpatient departments and the emergency room patient falls were not included in the data.

There was no documented review of the Patient's fall in the Medical Day Care Center provided to the Surveyor.

The Assistant VP of Performance Improvement was interviewed on the day of survey and accompanied the Surveyor during staff interviews. The Assistant VP of Performance Improvement said the Patient's fall was not reviewed within the Performance/Quality Department.

Review of the Orthopedic Consultation dated 08/14/09 indicated the Patient's right elbow x-ray showed a minimally displaced fracture. The Patient denied having pain with range of motion. The Orthopedic Surgeon indicated the Patient was provided with a posterior splint and sling.

There were no written written physician orders for the Patient's mobility post-fall and fracture.

Continued review of the Patient's medical record indicated the Patient was ambulated with the use of a rolling walker with the assistance of one person. It was not clear as to how the Patient ambulated with the rolling walker with the use of one arm.

The Team Leader was interviewed in person on 04/21/09 at 11:10 Am. The Team Leader said the next day after the Patient's fall, the staff were instructed not to leave patient's unattended in the bathroom The Team Leader said there were no written minutes taken at the staff meeting. The Team Leader was unable to recall who attended the meeting.

Based on record review, the Hospital failed to thoroughly review one of one Patient's who fell with injury following an invasive procedure requiring sedation.

The findings are as follow:

Refer to A- tag 0114.

Review of the Patient's Nursing Progress Note for Medical Day Care Center dated 08/13/09 at 3:45 PM and as reported by staff, the Patient was ambulated to the bathroom and found on the floor by a visitor. The Nursing Progress Note indicated the Patient sustained a bruise and right elbow laceration. The Nursing Progress Note indicated the Radiologist (who performed the Interventional Radiology procedure evaluated the Patient) was called and evaluated the Patient.

There was no written physician progress note post-fall identifying the Patient's assessment for injury or fall until 08/14/09 at 12 PM.

On 08/13/09 at 5:20 PM, Registered Nurse #1 indicated in the Functional Assessment that the Patient was at risk for falls. Registered Nurse #1 recommended the Patient be evaluated by a physical therapist.

There was no documentation the Patient was evaluated by a physical therapist prior to discharge to a long-term care facility.

Registered Nurse #2 was interviewed in person on 04/21/10 at 11:30 AM. Registered Nurse #2 said patients undergoing the invasive procedure were kept flat initially and then according to protocol raised to an upright sitting position. Registered Nurse #2 said the Patient was then positioned on the edge of the stretcher prior to being assisted to the bathroom. Registered Nurse #2 said the Patient requested a rolling walker, so one was provided. Registered Nurse #2 said the Patient was instructed to push the call bell button, located on the wall. Registered Nurse #2 said the patient requested a rolling walker and one was provided. Registered Nurse #2 left the Patient unattended.

Review of the Admission Nurses Note dated 08/13/09 at 6:20 PM indicated the patient was alert. the Patient complained of right elbow pain. The Patient denied having any backpain. Registered Nurse #4 indicated the Patient had a large ecchymotic site dressed with a Tegaderm and gauze. The affected area had scant bleeding and the dressing was intact. Registered Nurse #4 applied an ice pack. The Patient was provided with a bed alarm.

On 08/14/09 at 12 PM, Radiologist #2 indicated the Patient apparently had a fall post-procedure. Radiologist #2 indicated the Patient reported having right elbow pain. Radiologist #2 indicated the Hospitalist and an Orthopedic Surgeon were consulted to evaluate the Patient.

Radiologist #2 was interviewed in person on 04/21/10 at 3:40 PM. Radiologist #2 said physician hand-off was communicated via a message board located in the Interventional Radiology Department. Radiologist #2 had no verbal communication with Radiologist (#1). Radiologist #2 denied having any knowledge of the Patient's fall. Radiologist #2 said the Patient reported someone checked it out (the right elbow), the previous day. Radiologist #2 said the Patient reported the right elbow was painful. Radiologist #2 said trauma patients were not evaluated by the Radiology Department; so a consultation was obtained with the Hospitalist. Radiologist #2 said the Patient's x-ray taken on 08/14/09 showed a fracture. Radiologist #2 said the Patient's fall had not been reported at the time of transfer of care.

The Chief of Radiology was interviewed in person on 04/21/09 at 4:20 PM. The Chief of Radiology denied being informed of the Patient's fracture until the day of survey.

The Nurse Manager for an inpatient unit was interviewed on 04/21/10 at 2:40 PM. The Nurse Manager said the Hospital had a Falls Prevention Program which reviewed data for both patient falls with and without injury.The Nurse Manager said the outpatient departments and the emergency room patient falls were not included in the data.

There was no documented review of the Patient's fall in the Medical Day Care Center provided to the Surveyor.

The Assistant VP of Performance Improvement was interviewed on the day of survey and accompanied the Surveyor during staff interviews. The Assistant VP of Performance Improvement said the Patient's fall was not reviewed within the Performance/Quality Department.

Review of the Orthopedic Consultation dated 08/14/09 indicated the Patient's right elbow x-ray showed a minimally displaced fracture. The Patient denied having pain with range of motion. The Orthopedic Surgeon indicated the Patient was provided with a posterior splint and sling.

There were no written written physician orders for the Patient's mobility post-fall and fracture.

Continued review of the Patient's medical record indicated the Patient was ambulated with the use of a rolling walker with the assistance of one person. It was not clear as to how the Patient ambulated with the rolling walker with the use of one arm.

The Team Leader was interviewed in person on 04/21/09 at 11:10 Am. The Team Leader said the next day after the Patient's fall, the staff were instructed not to leave patient's unattended in the bathroom The Team Leader said there were no written minutes taken at the staff meeting. The Team Leader was unable to recall who attended the meeting.

There were no evidence that the Hospital reviewed patient falls with or without injury for the outpatient services.

Based on record review, physician and staff interview, there was no documentation for the assessment of one of one Patient's who fell following and invasive procedure with sedation in August 2009.

The findings are as follow:

Refer to A-tag 0114, and A-tag 0288.

Review of the Patient's Nursing Progress Note for Medical Day Care Center dated 08/13/09 at 3:45 PM and as reported by staff, the Patient was ambulated to the bathroom and found on the floor by a visitor. The Nursing Progress Note indicated the Patient sustained a bruise and right elbow laceration. The Nursing Progress Note indicated the Radiologist (who performed the Interventional Radiology procedure evaluated the Patient) was called and evaluated the Patient.

There was no written physician progress note post-fall identifying the Patient's assessment for injury or fall until 08/14/09 at 12 PM.

On 08/13/09 at 5:20 PM, Registered Nurse #1 indicated in the Functional Assessment that the Patient was at risk for falls. Registered Nurse #1 recommended the Patient be evaluated by a physical therapist.

There was no documentation the Patient was evaluated by a physical therapist prior to discharge to a long-term care facility.

Registered Nurse #2 was interviewed in person on 04/21/10 at 11:30 AM. Registered Nurse #2 said patients undergoing the invasive procedure were kept flat initially and then according to protocol raised to an upright sitting position. Registered Nurse #2 said the Patient was then positioned on the edge of the stretcher prior to being assisted to the bathroom. Registered Nurse #2 said the Patient requested a rolling walker, so one was provided. Registered Nurse #2 said the Patient was instructed to push the call bell button, located on the wall. Registered Nurse #2 said the patient requested a rolling walker and one was provided. Registered Nurse #2 left the Patient unattended.

Review of the Admission Nurses Note dated 08/13/09 at 6:20 PM indicated the patient was alert. the Patient complained of right elbow pain. The Patient denied having any backpain. Registered Nurse #4 indicated the Patient had a large ecchymotic site dressed with a Tegaderm and gauze. The affected area had scant bleeding and the dressing was intact. Registered Nurse #4 applied an ice pack. The Patient was provided with a bed alarm.

On 08/14/09 at 12 PM, Radiologist #2 indicated the Patient apparently had a fall post-procedure. Radiologist #2 indicated the Patient reported having right elbow pain. Radiologist #2 indicated the Hospitalist and an Orthopedic Surgeon were consulted to evaluate the Patient.

Radiologist #2 was interviewed in person on 04/21/10 at 3:40 PM. Radiologist #2 said physician hand-off was communicated via a message board located in the Interventional Radiology Department. Radiologist #2 had no verbal communication with Radiologist (#1). Radiologist #2 denied having any knowledge of the Patient's fall. Radiologist #2 said the Patient reported someone checked it out (the right elbow), the previous day. Radiologist #2 said the Patient reported the right elbow was painful. Radiologist #2 said trauma patients were not evaluated by the Radiology Department; so a consultation was obtained with the Hospitalist. Radiologist #2 said the Patient's x-ray taken on 08/14/09 showed a fracture. Radiologist #2 said the Patient's fall had not been reported at the time of transfer of care.

Review of the Orthopedic Consultation dated 08/14/09 indicated the Patient's right elbow x-ray showed a minimally displaced fracture. The Patient denied having pain with range of motion. The Orthopedic Surgeon indicated the Patient was provided with a posterior splint and sling.

There were no written written physician orders for the Patient's mobility post-fall and fracture.

Continued review of the Patient's medical record indicated the Patient was ambulated with the use of a rolling walker with the assistance of one person. It was not clear as to how the Patient ambulated with the rolling walker with the use of one arm.

The Team Leader was interviewed in person on 04/21/09 at 11:10 Am. The Team Leader said the next day after the Patient's fall, the staff were instructed not to leave patient's unattended in the bathroom The Team Leader said there were no written minutes taken at the staff meeting. The Team Leader was unable to recall who attended the meeting.